Download Basal Tako-Tsubo cardiomyopathy: an uncommon case of TTC in in

CASE REPORT
258
An uncommon case of T TC in in a young woman with multiple sclerosis
Basal Tako-Tsubo cardiomyopathy
Mattia Cattaneo a , Alessandra Pia Porretta a , Carlo Cereda b , Marco Moccetti c , Claudio Gobbi b , Elena Pasotti c ,
Daniel Sürder c , Claudio Städler b , Augusto Gallino a, d
a
Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland; b Department of Neurology, Neurocenter of
Southern Switzerland, Ospedale Regionale, Lugano, Switzerland; c Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland;
d
University of Zürich, Switzerland
1C–D). Although cardiac magnetic resonance imaging
Summary
(MRI) was not performed, the diagnosis of myocarditis
Tako-Tsubo cardiomyopathy (TTC) is an infrequent, mostly stress-related transient
cardiomyopathy, which mainly affects postmenopausal women. Inverted or basal TTC
(B-TTC) episodes are rarer. Our case illustrates a rare example of B-TTC in a 30-year-old
woman with an acute multiple sclerosis relapse as the associated stressor, possibly providing a hypothetical pathological substrate for this TTC episode. This uncommon case
suggests that both factors of young age or neurological events may affect TTC pattern
during one episode. Moreover, this case raises the question as to whether researchers
on TTC should adopt a new perspective, embracing cardiovascular as well as neuroanatomical and -functional features.
Key words: Tako-Tsubo cardiomyopathy; apical-sparing; multiple sclerosis; young age
was reasonably rejected owing to the absence of systemic inflammation (normal C-reactive protein, leucocyte and procalcitonin values), negative bacterial blood
cultures and viral tests. Phaeochromocytoma was excluded because of normal 24-hour urine fractionated
catecholamines and metanephrines. Two days later the
ECG showed complete spontaneous normalisation (fig.
2). Thus, the diagnosis of basal (inverted) Tako-Tsubo
cardiomyopathy (TTC) was retained.
Cerebrospinal MRI performed 5 days before the TTC episode showed an acute inflammatory lesion affecting
dorsal medulla (fig. 1E). This area is involved in cardio-
Case report
vascular homeostasis and regulation of autonomic responses to stressful events through sympathetic drive
The current report describes a 30-year-old Caucasian
[1], thus providing a hypothetical pathological sub-
woman who came to our attention because she pre-
strate for this TTC episode. This medullary lesion re-
sented with a rapidly progressing bilateral proprio-
covered at 5-month MRI follow-up.
ceptive ataxia, spinothalamic hypoaesthesia and gait
impairment. Two years before, the patient had experienced an analogous neurological episode. Medical history, clinical, laboratory and imaging findings sup-
Discussion
Tako-Tsubo cardiomyopathy (TTC) is an infrequent,
ported the diagnosis of an acute multiple sclerosis
mostly stress-related transient cardiomyopathy, which
relapse according to McDonald criteria. Intravenous,
is currently poorly understood and simulates acute
and later oral, steroid therapy was implemented with
coronary syndrome in the absence of significant ob-
suboptimal patient relief. Ten days later the patient
structive lesions on coronary angiography [2]. TTC
was transferred to the coronary care unit because of
mainly affects the midapical segments of the left ven-
acute typical chest pain. With the exception of ongoing
tricle in postmenopausal women and apical-sparing
significant neurological impairment no further clini-
TTC episodes are rare [2]. Relying on a few case reports
cal findings nor haemodynamic compromise were
and a small observational trial, some investigators
present. The electrocardiogram (ECG) showed diffuse
have raised the question of whether inverted or basal
ST-segment depression (fig. 1A), the corrected QT-inter-
TTC (B-TTC) may be associated with young (premeno-
val was not prolonged (409 msec) and brain natriuretic
pausal) age [3–6], neurological events that act as psy-
peptide (BNP) levels were not measured. Transthoracic
cho-physical stressors, and/or acute and sub-acute
echocardiography showed akinetic basal segments (fig.
neurological events acting as psychophysical stressors
1B: 4-chamber view, end-systole: arrows) and apical hy-
[7].
percontractility with slightly reduced (45–50%) left
Our case illustrates a rare example of B-TTC in a
ventricle ejection fraction (LVEF%) (see online Video 1:
30-year-old woman with an acute relapse of multiple
four-chamber view). These findings were inconsistent
sclerosis acting as an associated stressor. Approxi-
with a moderate increase in serum troponin (peak 3.5;
mately 90% of reported TTC cases occur in postmeno-
reference value <0.09). The patient immediately under-
pausal women of advanced age and are mostly related
went selective coronary angiography, which disclosed
to emotional or physical stress [2, 8]. There is evidence
the absence of any coronary stenosis or dissection (fig.
that a pathophysiological association between neuro-
CARDIOVASCULAR MEDICINE – KARDIOVASKULÄRE MEDIZIN – MÉDECINE CARDIOVASCULAIRE
2015;18(9):258–260
CASE REPORT
259
Figure 1: Acute phase ECG shows diffuse ST-segment depression. (A) Transthoracic echocardiography, 4-chamber view, end-systole (B) shows akinetic
basal segments (arrows) and apical hypercontractility (see also online Video 1). Selective left (C) and right (D) coronary artery angiography show absence
of any coronary stenosis or dissection. (E) Axial T2-weighted MRI showing an acute dorsal medullary inflammatory lesion affecting the solitary tract and
the ventro-lateral medulla (arrow).
logical disorders and TTC may exist [7]. Diagnostic cri-
tion of whether TTC episodes related to all sorts of
teria have been published excluding TTC in the case of
acute neurological events should be classified as TTC in
acute cerebrovascular events and critically ill patients
future diagnostic criteria and whether TTC diagnostic
[2, 8, 9].
criteria should be revised. Lastly, it suggests that fu-
Previously described cases have suggested that AS-TTC
ture research on TTC should be based on a new per-
is associated with either young age or neurological
spective, embracing cardiovascular as well as neuroan-
events. This uncommon case suggests that both condi-
atomical and -functional features.
tions may affect TTC pattern during the same episode
and that it should be considered for the patient’s
correct management. It has actually been shown that
different TTC patterns may be associated with different
complications and short-term mortality [10]. Furthermore, only acute cerebrovascular events are currently
considered exclusion criteria. This case raises the ques-
CARDIOVASCULAR MEDICINE – KARDIOVASKULÄRE MEDIZIN – MÉDECINE CARDIOVASCULAIRE
Video on www.cardiovascmed.ch:
Transthoracic echocardiography (4-chamber view) end-systole: it displays left ventricle (LV) wall motion abnormalities
with akinetic basal segments, apical hypercontractility and
moderately reduced LV ejection fraction.
2015;18(9):258–260
CASE REPORT
260
Figure 2: Post-acute phase ECG demonstrates complete normalisation of repolarisation within two days.
Authors’ contribution
All authors take responsibility for all aspects of the reliability and
freedom from bias of the data presented and their discussed
interpretation.
Disclosure statement
No financial support and no other potential conflict of interest
relevant to this article were reported.
References
Correspondence:
Mattia Cattaneo, MD
Clinical and Research fellow
Cardiovascular Medicine
Department – Ospedale
Regionale di Bellinzona e
Valli, San Giovanni (EOC),
Via Soleggio
CH-6500 Bellinzona
Switzerland
mattia.cattaneo[at]eoc.ch
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